Predictors of adverse outcomes after transcatheter mitral valve replacement

ABSTRACT

Introduction: Transcatheter mitral valve replacement (TMVR) is still a recent technology with numerous unknowns but also great promises. The risk of complications reported in observational studies have limited its adoption by interventional cardiology and surgical communities.

Areas covered: Some of the major setbacks of TMVR are complications related to the devices and those related to the pathway. Device-related complications include left ventricle outflow tract (LVOT) obstruction, transcatheter heart valve (THV) dislocation or embolization, thrombosis, and stroke. The transapical approach currently remains the main pathway for TMVR but is associated with high risk of major bleeding and residual apical myocardial scarring. Complication prediction and prevention seem possible. Device-related complication prediction is based on pre-operative imaging including multi-slice computed tomography with 3-dimensional reconstructions and echocardiography which allow LVOT obstruction prediction and appropriate sizing aiming at avoiding dislocation. Industry should aim at the development of transfemoral delivery systems. Nevertheless, several recent feasibility observational studies suggested acceptable safety and efficacy of transcatheter mitral valve replacement.

Expert opinion: TMVR complications and transapical delivery are some of the main setbacks which need to be addressed for TMVR to be adopted for broad clinical use.

KEYWORDS:

• TMVR
• TMVR
• mitral valve
• mitral replacement

Article highlights box

• Transcatheter mitral valve replacement (TMVR) is a recent but fast-growing technology.

• Left ventricle outflow tract obstruction, THV dislocation or embolization, bleeding, and thrombosis are some of the major complications of TMVR, but they seem to be preventable.

• Device-related complication prediction is based on pre-operative imaging including multislice-computed tomography with 3-dimensional reconstructions as well as echocardiography.

• Transseptal delivery systems is likely to reduce the risk of major bleeding which is currently an important setback of transapical TMVR.

• Appropriate criteria need to be set for patients to be addressed for TMVR and structural valve deterioration.

• Theorical ground seems more promising for TMVR than transcatheter mitral valve repair, but this hypothesis remains to be tested.

Declaration of interest

T Modine is a consultant for Boston Scientific, Medtronic, Edwards, Cephea, Microport, GE, Abbott; he received a research support grant from Edwards. Dr Nicolo Piazza declares to be consultant/proctor for HighLife, Medtronic and MicroPort, and is a consultant for Cephea. J Granada received Grant/Research Support by Abbott Vascular, Amaranth Medical, Angiometrix, AstraZeneca, Bioventrix, Boston Scientific, Caliber Therapeutics, Cardia, Cardiac Implants, Cagent, Cardiovascular Systems Inc., Cardiosolutions, Celladon, Cephea, Circulite/Heartware, ControlRad, CorindusVascular Robotics, CR Bard/Lutonix, DC Devices, Direct Flow Medical, Draper, Edwards LifeSciences, FulgurMedical, Guided Delivery Systems, Intact Vascular, Lutonix, Marvel Medical, Medtronic, Mercator, MedAlliance, MerilLife Sciences, Microvention, MicroInterventionalSystems, Mitralign, Neovasc, Nitiloop, Nitinotes, OrbusNeichMedical, REVA Medical, Siemens, Sonivie, Spectranetics, Svelte, Stentys, Surmodics, Thoratec, UniQure, Volcano, WL Gore, Zenvalve. Equity Position/Consulting in Cephea. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer Disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

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Funding

This paper was not funded.